Information Collection

CryptoNet Case Report Form

IC 248663 under ICR 202106-0920-015 · OMB 0920-1360.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1360 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CryptoNet Case Report Form	Form and Instruction
Att C_CryptoNet form 2021_6.28.21.docx	Other-WORD version of CRF to facilit
Att C_CryptoNet form 2021_6.28.21.docx	Other-WORD version of CRF to facilit
CryptoNet Case Report Form Att C_CryptoNet form 2021_6.28.21.pdf	Form and Instruction
CryptoNet Case Report Form Att C_CryptoNet form 2021_6.28.21.pdf	Form and Instruction

IC Title:

CryptoNet Case Report Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	n/a	CryptoNet Case Report Form	Att C_CryptoNet form 2021_6.28.21.pdf		No		Paper Only
Other-WORD version of CRF to facilitate review and editing of content			Att C_CryptoNet form 2021_6.28.21.docx		No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	125	125
Annual IC Cost Burden (Dollars)	3,215	3,215

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.